Transcript MGR Case Report - Clinical Correlations

Clinical Correlations
The NYU Internal Medicine Blog
A Daily Dose of Medicine
http://clinicalcorrelations.org
Medical Grand Rounds
Clinical Vignette
November 12th, 2008
Jon-Emile Kenny M.D.
Chief Complaint
55 year old female presents with a
large, ulcerating breast mass and
associated supraclavicular and left
axillary lymphadenopathy.
History of Present Illness
Patient first noticed the mass 2 years prior and
went to an outside hospital for evaluation.
At that time, review of systems was noncontributory.
History of Present Illness
A fine needle aspiration and core biopsy of an
axillary lymph node and breast mass revealed
poorly differentiated invasive ductal
adenocarcinoma.
The carcinoma was estrogen receptor-negative,
progesterone-receptor negative and HER2
receptor positive.
History of Present Illness
A staging CT scan was significant for probable
liver and bone metastases.
The patient was lost to follow up until her current
presentation.
On presentation, the patient complained of
significant pain of her left breast. She noted that
her breast had become ulcerated over the
previous weeks to months, but only recently had
started to have foul-smelling discharge.
History
Past Medical History:
– none
Past Surgical History:
– none
History
Social Hx:
Family Hx:
Allergies:
Medications:
Pt. had lost her home in the
interim and was living with family.
Non-contributory
No known drug allergies
none
Review of Systems:
– Chronic fatigue
– Remainder of review of systems negative
Physical Exam
General: middle-aged female in no acute distress,
sitting comfortably, Alert and Oriented x3.
T:97.3oF BP:132/76 HR:75 RR:18 O2:99%RA
Breast: Left breast completely ulcerated, crater-like
with granulation tissue without discharge. Left
lymphadenopathy of axilla.
The remainder of the physical exam was normal
Working Diagnosis
Locally advanced, invasive ductal
adenocarcioma.
Laboratory
WBC 10.7 mm3 (nl 4.5-11)
Hemoglobin 6.3 g/dL (13.5-16.5), MCV 63.0
Coagulation studies normal
Liver enzymes normal
Basic Chemistries normal
CEA 1.8 (nl < 5)
CA 27.29 was 339.4 (nl < 40)
Imaging
Chest XR: Bilateral pulmonary nodular densities
Bone Scan: Suspicion for bone metastases in
T4/5 spinous process.
Chest CT: Innumerable lung, liver and osseous
metastases
Abdomen/Pelvis CT: New lytic lesions in L4,
multiple liver and bone lesions.
Hospital Course
The patient was admitted and was transfused for
her anemia. Her tumour was biopsied, but
deemed inoperable by the surgical service
because of bleeding risk.
She received a course of antibiotics for superinfection of her breast mass.
She was seen by radiation oncology for
palliative XRT and received Trastuzumab
(Herceptin) chemotherapy.
Pt. was discharged with Oncology follow up.
Follow-up
Patient has been seen in clinic and is at her
baseline. Biopsy has confirmed what was found
at the outside hospital. She continues XRT and
Trastuzumab (Herceptin) chemotherapy.
Final Diagnosis
Metastatic HER2 positive, estrogen-receptor
negative, progesterone-receptor negative ductal
adenocarcioma.